Baylor University Medical Center Proceedings October 2017 - 452

Sinonasal and laryngeal sarcoidosis
Hawa Edriss, MD, John Kelley, BS, and Joshua Demke, MD

Sarcoidosis is a chronic granulomatous
inflammation of uncertain etiology that
can involve any organ system in the body.
Sinonasal and laryngeal involvement is
rare, poorly understood, and difficult to
diagnose. Additionally, the extent of the
disease is variable, and the response to
systemic corticosteroids is often poor. We
report a case of a 55-year-old woman with
prior cutaneous sarcoidosis who presented with chronic nasal congestion, difficulty
breathing, dysphonia, and stridor, and biopsy of the nasal vestibule revealed noncaseating granulomatous inflammation.

Figure 1. Cutaneous manifestations of sarcoidosis: (a) lupus pernio; (b) well-demarcated dark plaques with scarring
on the patient's arm.

inonasal and laryngeal involvement is a rare presentation
of extrapulmonary sarcoidosis and occurs in about 1%
of patients with sarcoidosis. Both types of involvement
are clinically challenging, with unclear treatment options. Delayed diagnosis is common due to nonspeciﬁc upper
respiratory presentation that can mimic several disorders.
Laryngeal sarcoidosis can progress to severe airway obstruction
and potentially life-threatening complications.
CASE DESCRIPTION
A 55-year-old black woman with a history of obstructive
sleep apnea and cutaneous sarcoidosis on oral corticosteroids
presented with nasal stuﬃness and obstruction, nasal discomfort, hoarseness, and diﬃcult breathing made worse by lying
down and alleviated by sitting up. Her symptoms started several
months earlier and increased in severity several weeks prior to
presentation. She had no fever, chills, cough, or weight loss.
Physical examination revealed audible stridor and dark-colored
skin plaques involving the nose in a butterﬂy distribution, the
nasolabial folds, cheeks, forehead, and right arm (Figure 1). Her
oral cavity examination revealed tender swollen gums and loose
premaxillary teeth. Her vital signs and laboratory results were essentially normal except for an elevated erythrocyte sedimentation
rate of 55 mm/hr (reference range, <30 mm/hr) and C-reactive
protein of 1.4 mg/dL (reference range, <0.5 mg/dL). Her serum
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calcium level was normal at 9.3 mg/dL. Computed tomography
(CT) of the neck revealed complete opaciﬁcation of the left
maxillary antrum with outward expansion of the sinus walls, an
8 mm mucous retention cyst in the right maxillary sinus, bilateral
maxillary erosions, and destruction of the premaxilla, palate, and
ﬂoor of the nose suspicious for malignancy (Figure 2). Sinonasal
endoscopy showed bilateral narrowed nasal vestibules with a
cobblestone mucosa and extensive nasal crusting and obstruction; biopsy of the right nasal vestibule revealed chronic noncaseating granulomatous inﬂammation (Figure 3). CT of the chest
revealed bilateral hilar lymphadenopathy and four pulmonary
nodules <2 cm in size. The patient underwent a bronchoscopic
examination, which revealed an edematous and pink epiglottis
and aryepiglottic and ventricular folds and a subglottic nodular
lesion (Figure 4). Diﬀuse yellowish endobronchial nodular lesions with underlying mucosal hyperemia involving the entire
airway were present (cobblestone respiratory mucosa).
The patient was started on a high-dose systemic corticosteroid, oral methotrexate 12.5 mg once weekly, and azelastineﬂuticasone 137 mcg-50 mcg nasal spray twice daily. However,
she had multiple emergency department visits and readmissions
From the Department of Internal Medicine, Texas Tech University Health Sciences
Center, Lubbock, Texas.
Corresponding author: Hawa Edriss, MD, Department of Internal Medicine, Texas
Tech University Health Sciences Center, 3401 4th Street, Lubbock, TX 79430
(e-mail: Hawa.edriss@ttuhsc.edu).
Proc (Bayl Univ Med Cent) 2017;30(4):452-454

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017